1234 Name Full nameOrganisationPhone numberEmail address Postal Address Street Address Address Line 2 Town / City County Post code If you are an organisation then please tell us moreHow long have you been operating for?What do you do?Have you any prior experience in running this type of asset or community initiative?Are you a Registered charity Industrial and provident society Community interest company Social enterprise Other voluntary organisation – please describe Details Your interestSelect the community your are internested in— select a Community —Ashburton/BuckfastleighAxminsterBarnstapleBidefordBrauntonCreditonCullomptonDartmouthDawlishDevon-wideEcmouthExeterExmouthGreat TorringtonHolsworthyHonitonIlfracombeIvybridgeKingsbridgeLynton/LynmouthMoretonhampsteadNewton AbbotOkehamptonOttery St MarySeatonSidmouthSouth MoltonTavistockTeignmouthTivertonTotnesWhich service review (if any) referred you to this form?I am interested in talking to you about an asset or assets Yes No (if yes, please specify which one): Which asset Add RemoveI am interested in talking to you about setting up a new community initiative Yes No Please provide us with a brief outline of your proposal. Please include any information on how it (asset/community initiative) will be sustained:Please briefly set out how your proposal will help to meet agreed local priorities or recognised needs:Could you operate out of other local community facilities? If so, please specify:What kind of support do you think you would need to start to turn your proposal into a reality? Other supporting informationPlease describe what wider community support you have for this proposal:Have you discussed your proposal with any other local organisations? If so, please specify which ones and whether there is any potential to develop your proposal in partnership with them:To help us facilitate a wider discussion in your community we would like your consent to share your submitted information with other interested parties and publish this on this website. This would be really in helping foster a fuller conversation in your community on the services and assets that it wants and needs. Thank you.I consent to my details being shared with others for this purpose: Yes No Please enter the characters shown in the box provided to confirm your submission:EmailThis field is for validation purposes and should be left unchanged. Δ